Are cancer patients getting inadequate care in your ED?

After ED nurses detected a mild fever in a cancer patient, a decision was made to start treatment after the patient was admitted to the floor.

"It was over three hours before the patient had the first dose of antibiotic, and the patient subsequently died," says Linda Young, RN, MSN, faculty member at Montana University College of Nursing-Missoula Campus.

It’s unknown whether this patient’s death could have been prevented if treatment had been started immediately in the ED, but one thing is certain: Cancer patients with life-threatening emergencies are at risk for being undertreated in EDs, she says.

"ED nurses may mistakenly undertreat pain, immobility, or gastrointestinal issues due to lack of understanding of the underlying problem," Young warns.

If a patient with breast cancer told you she was unusually tired lately, would you suspect hypercalcemia? "This is the most common life-threatening disorder associated with cancer," says Gail McWilliams, RN, CCRN, CEN, clinical nurse specialist for the ED at Shore Health System in Cambridge, MD.

Symptoms may be very vague, including fatigue, confusion, and signs of dehydration, and they may occur gradually, she adds. "Large amounts of urine combined with decreased appetite, nausea, vomiting, and other signs of dehydration are good clues."

To improve care of patients with oncological emergencies, do the following:

• Give enough pain medication.

Pain may be severe enough to bring a cancer patient to the ED, and patients may require much higher doses than usually administered, says Young. "The uncontrolled pain of the cancer patient may be underestimated."

• Review treatment history.

You need to know which pain medications the patient is taking and in what dosages, says Young. "If the patient has recently had chemo, it is important to know this, as many types of chemo are excreted in their original state, and extra precautions may be needed when contacting body fluids," she says. "If the patient has had a radiation implant, it would be important to know if anyone is pregnant, as they would have to avoid this person."

• Consider underlying conditions.

Bowel obstruction from an encroaching tumor may be dismissed as constipation, or back pain from spinal cord compression may be mistaken for a sprain, says Young.

Ken Lanphear, RN, ED nurse at Borgess Medical Center in Kalamazoo, MI, says, "It is easy to be sidetracked and attribute the presenting signs and symptoms to cancer, when in fact it may be a problem in another system."

For example, a lung cancer patient with a cardiac history may complain of shortness of breath — but is this symptom cased by cancer or heart disease? "It becomes easy to blame everything on the cancer, but we must remember that the patient may have other medical problems," says Lanphear.

• Don’t overlook life-threatening emergencies.

Perform a careful physical assessment to avoid missing a potentially life- or limb-threatening disease process, McWilliams says. Here are oncological emergencies you may see in your ED, with assessment tips for each:

— Neutropenic infection. This is the leading cause of death in patients undergoing cancer treatment, and it is imperative to start treatment immediately with broad-spectrum antibiotics, urges Young.

Symptoms can be very subtle, and patients may present only with a low-grade fever or no fever at all, says McWilliams. "Murmurs may be present secondary to anemia or intracardiac vegetation," she says. "Your skin assessment must be meticulous, with all sites of recent invasive procedures checked."

Watch for signs of early sepsis, says McWilliams. "When antibiotics are started, vital signs should be monitored frequently in the first hour," she says. "The release of endotoxins can cause refractory hypotension."

— Superior vena cava (SVC) syndrome. This is most often seen with bronchogenic cancers, but any tumor in the mediastinum can compress or invade the SVC, says McWilliams. The most common symptoms are facial, neck, and bilateral upper extremity swelling, dyspnea and cough, but the patient also could present with headache or other signs of increased intracranial pressure, dysphagia, and hoarseness, she says.

— Spinal cord compression. "This is a medical emergency and can cause permanent paralysis if not treated promptly," McWilliams warns. Pain is constant, may increase in the supine position, and may cause the patient to awaken at night, she adds.

"Radicular pain is caused by pressure on the nerve roots, especially in the affected dermatome," McWilliams says. It can be relieved by sitting upright, she says.

"This is the exact opposite of what is seen in patients with a slipped disc," McWilliams says.

— Syndrome of inappropriate antidiuretic hormone secretion. This is an endocrine disorder of water intoxication, most commonly caused by a lung malignancy, says McWilliams. "Look for signs of dehydration or fluid excess," she advises.

— Tumor lysis syndrome. "This emergency is frequently triggered by administration of chemotherapy," says McWillliams. Dehydration, hyperkalemia, hyperuricemia, and hyperphosphatemia with associated hypocalcemia can produce acute renal failure, she warns. "Ask the patient about intake and urine output."

Sources

For more information, contact:

  • Ken Lanphear, RN, BSN, Emergency Department, Nurse, Borgess Medical Center, Kalamazoo, MI. Telephone: (269) 383-8232. E-mail: kenl55@yahoo.com.
  • Gail McWilliams, RN, CCRN, CEN, Clinical Nurse Specialist, Emergency Department, Shore Health System, Cambridge, MD. Telephone: (410) 822-1000, ext. 8019. E-mail: gmcwilliams@shorehealth.org.
  • Linda Young, RN, MSN, Montana State University, College of Nursing, Missoula Campus, Missoula, MT. Telephone: (406) 243-2623. E-mail: lyoung@montana.edu.